Page 701 - Clinical Application of Mechanical Ventilation

Case Studies 667

day. At this pressure support range, the patient was able to achieve a tidal volume
of 300 to 400 mL. As muscle strength returned and gradually improved, less pres-
sure support was necessary to maintain an adequate tidal volume. The patient was
allowed to rest completely at night on A/C mode, and weaning was resumed each
morning to CPAP with low level of pressure support.
By day 59, the patient was able to tolerate 40 minutes to an hour off the ventilator
every 2 to 4 hours during the day while resting at night. Each day brought the same
monotonous routine, but the patient continued to improve with longer periods free
from the ventilator. On ventilator day 68 he was able to remain off the ventilator
24 hours per day. Rehabilitation had just begun!

Complications

This patient encountered almost complete paralysis in the acute pathologic phase of
his disease as he was only able to blink his eyes. He was under severe emotional and
psychological stress throughout his hospitalization due to his complete paralysis
and his reliance on others for care. He developed GI bleeding from a duodenal ulcer
for which he was treated with Zantac® via his feeding tube. Otitis media developed
and was treated with broad-spectrum antibiotics, and a persistent left lower lobe
pneumonitis required bronchoscopy. Rehabilitation was begun and he was trans-
ferred out of the intensive care unit with humidified O at an F O of 30%. The
2
2
I
tracheostomy was gradually buttoned and eventually removed. He required only
2 L/min of oxygen via nasal cannula while recovering in rehab. The patient was
discharged after 154 days of hospital stay (last 94 days in extensive rehabilitation)
on room air requiring only 25 mg of prednisone and follow-up physical therapy. He
continued to progress and, eventually, demonstrated no residual effects from this
debilitating illness.
References (lavage and suctioning):
Ackerman, M. H. (1993). The effect of saline lavage prior to suctioning, Journal of
Critical Care, 2(4), 326–330.

Pedersen, C. R. (2009). Endotracheal suctioning of the adult intubated patient—
what is the evidence? Intensive and Critical Care Nursing, 25(1), 21–30.

CASE 12: BOTULISM

INTRODuCTION

J.D. was a 66-year-old, 50-Kg female in her usual state of health until she consumed
a partial jar of home-canned salsa. The following day she developed abdominal
cramping thought to be the flu. Her intermittent cramping continued for 48 hours
post-ingestion, and she subsequently developed slurred speech and blurred vision.

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